Keiichiro Takasuna

Surgery for Mycobacterium avium complex lung disease in the clarithromycin era

OBJECTIVE Since the introduction of clarithromycin, it has been assumed that pulmonary Mycobacterium avium complex (MAC) disease can be treated with medication alone. This study examines whether surgery can still play an important role in the management of MAC lung disease in the current era. METHODS Between April 1993 and January 2001, 21 patients (11 men and 10 women) underwent a pulmonary resection for MAC infection. The median age of the patients was 56 years (range: 27-67 years). None of the patients were immunocompromised. Regimens employing clarithromycin were initiated preoperatively in all patients. The indications for surgery were failure of drug therapy in 19 patients and discontinuation of chemotherapy because of drug toxicity in two patients. The pulmonary resections (19 right lung, 2 left lung) performed included lobectomy in 16 patients, pneumonectomy in three, bilobectomy in one, and lobectomy plus segmentectomy in one. RESULTS All of the patients survived the surgery. Six major postoperative complications occurred in six patients (28.6%) and these included two bronchopleural fistulas after right pneumonectomy, two space problems, one prolonged air leak, and one case of interstitial pneumonia. All postoperative complications were manageable, and four of these were treated surgically. All patients had sputum-negative status after their operation. Relapse occurred in two patients (9.5%) at six months and two years postoperative, respectively. The first patient, who originally had a right upper lobectomy, underwent a left upper lobectomy during the follow-up period, attaining sputum conversion. The second patient underwent a right pneumonectomy and then died of respiratory failure four years postoperatively. This one late death was the only fatality. CONCLUSIONS Although it is associated with relatively high morbidity, surgery provides a high sputum conversion rate for patients whose MAC disease responds poorly to drug therapy. Even in the present clarithromycin era, pulmonary resection remains the treatment of choice when MAC lung disease has not been successfully eradicated by drug treatment alone.

Three-dimensional imaging navigation during a lung segmentectomy using an iPad.

OBJECTIVES The requirement for anatomical lung segmentectomies has increased in recent years but this surgical procedure is relatively difficult. We herein present the benefits of using three-dimensional (3D) imaging navigation during a lung segmentectomy via the intra-operative use of an iPad. METHODS Fourteen patients who had undergone an anatomic segmentectomy for a primary lung cancer or a metastatic lung tumour between 1 October 2010 and 30 April 2011 were included in this study. Contrast-enhanced scanning was performed twice on each patient, and 3D images were constructed using a workstation. These images were then transferred to an iPad and analysed during the operation using DICOM image viewer software. RESULTS The study group included 3 men (21%) and 11 women (79%) ranging in age from 57 to 83 (mean 69 ± 7.8 years). The operative procedure involved a resection in one case each of the right S1, the right S2, the right S2 + S6a, the right S3, the right S6, the left S8 and the left S8 + 9. The left S1 + 2 and the left basal segment were resected in two cases. The left upper division was resected in three cases. All segmentectomies were successful and no major post-operative complications developed in any patient during or after their procedures. No positive margins were detected pathologically. CONCLUSIONS A 3D computed tomography navigation using an iPad enhances the ability to perform a safe and secure segmentectomy.

Different efficacy of CT screening for lung cancer according to histological type: Analysis of Japanese-smoker cases detected using a low-dose CT screen

The efficacy of CT screening for lung cancers is still a controversial issue, although one of the recently publicized large randomized controlled trials of this methodology, the National Lung Screening Trial (NLST), reported a decrease in the lung cancer-specific mortality for heavy smokers. We here performed case-matched comparative analyses, as a retrospective study, of three lung cancer arms detected by CT screen, X-ray screen, and by individual analysis of the clinicopathological features and outcomes in smokers from a symptomatic-prompted group of patients. We also considered the impacts of various potential biases in this cohort. The total study cohort comprised 136 patients in the CT screen group, 263 in the X-ray screen group and 254 in the symptomatic-prompted group. The ratio of stage IA cancers in the CT screen group was 67.7% and the ratio of advanced cases (i.e. stages IIIB+IV) was 12.5%. The percentage of bronchioloalveolar carcinoma (BAC) was 28.7% in the CT screen group. The 5-year survival rates were 82.4% in the CT screen group, 38.0% in the X-ray screen group and 17.8% in the symptomatic-prompted group. CT screening was found to be an independent prognostic factor for lung cancer even when BAC cases were eliminated (HR 0.35, P<0.01). Based on our sub-analysis by individual histological sub-type, CT screen lung cancer cases had a better survival rate than non-screened patients, which included adenocarcinoma, squamous cell carcinoma and large/small cell carcinoma. However, by multi-variant analysis a CT scan would not be expected to reduce the risk of lung cancer mortality in patients with large/small cell carcinoma, although would be expected to reduce the risk of lung cancer death by 80% in cases of both adenocarcinoma and squamous cell carcinoma. In conclusion, our current findings indicate that CT screening for lung cancer is an effective strategy for smokers and that patients with adenocarcinoma and squamous cell carcinoma of all variant histological types may benefit from this test. In this regard, early stage large/small cell carcinomas are insufficiently detected by the existing annual screening system.

Efficacy of CT screening for lung cancer in never-smokers: Analysis of Japanese cases detected using a low-dose CT screen

CT-screening for lung cancer is fairly widely used for both smokers and never-smokers in East Asia because the mortality rate for never-smokers due to this cancer is relatively high in this region. We performed comparative analyses, as a retrospective study, on three lung cancer arms detected by CT-screen, X-ray-screen, and via analysis of clinicopathological features and outcomes in never-smokers from a symptomatic-prompted group of patients. The total study cohort comprised 218 patients in CT group, 160 in X-ray group, and 82 in symptomatic-prompted group. The percentage of bronchioloalveolar carcinoma (BAC) was 65.1% in CT-screen group. The ratio of stage IA tumors in CT-screen group was 88.5% and the ratio of advanced cases (i.e. stages IIIB+IV) was 2.3%. The 5-year-survival rates were 95.0% in CT-screen, 73.0% in X-ray-screen and 40.0% in symptomatic-prompted group. We performed further sub-analysis which excluded pure BACs (i.e. Noguchi types A and B) or pure GGOs within a 10mm diameter because this is indicative of a very favorable prognosis. Based on this sub-analysis the number of the subjects in each group became 76 in CT group; 140 in X-ray group and 77 in symptomatic-prompted group. The principal characteristics of the patients such as age and sex became almost even in the three arms. In CT-screen subgroup, the ratio of stage IA cancer was 69.7% and of advanced cases was 6.6%. This advanced ratio was lower than both X-ray-screen (22.1%) and symptomatic-prompted (61.9%) groups. The 5-year-survival rates were 89.9% among CT-screen group patients, 72.6% for X-ray screen cases and 39.1% in symptomatic-prompted group. A CT-screen was found to be one of the independent prognostic factors for lung cancer (HR, 0.28; 95% CI, 0.12-0.72) and based on this would be expected to reduce the risk of lung cancer death by 78% compared with non-screened cases. In conclusion, CT will improve the survival rate and decrease the rate of advanced cancers in never-smokers via the existing annual screening system. CT-screening is also an independent prognostic improvement factor in never-smokers, and will therefore reduce the risk of lung cancer death.

Successful lung lobectomy for a lung cancer following thoracic endovascular aortic repair for a thoracic aortic aneurysm: report of a case

Lung cancer and a thoracic aortic aneurysm were detected simultaneously in a 79-year-old male patient with diabetes. The aneurysm was first treated by thoracic endovascular aortic repair. A right lower lobectomy was subsequently performed after the blood flow of the bronchial and intercostal arteries was confirmed by computed tomographic angiography. The bronchial stump was covered with an intercostal muscle flap. The patient’s postoperative course was uneventful. Thoracic endovascular aortic repair is a useful and less invasive treatment for such cases, but a blood flow evaluation of the aortic branches should be done following this procedure before a lung resection is considered.

Cardiophrenic angle lymph node metastasis from a fallopian primary tumor.

Isolated cardiophrenic angle node metastases are relatively rare, as are primary fallopian tube carcinomas. We describe a case of a cardiophrenic angle node metastasis from such a tumor, with no peritoneal involvement. A 52-year-old woman, who had been previously diagnosed with fallopian tube carcinoma, was referred with a right cardiophrenic angle mass. A thoracoscopic resection was performed. The pathological diagnosis was lymph node metastasis from the primary lesion.

Coexistence of a pulmonary adenocarcinoma with a focal organizing pneumonia

We report a case of a pulmonary adenocarcinoma in coexistence with an organizing pneumonia. A 73-year-old male presented with an abnormal shadow on a chest X-ray. The pathological diagnosis, made via a partial resection, was a focal organizing pneumonia with reactive proliferation of the bronchial epithelium. Three years later, two tumors adjacent to the staple line were revealed by computed tomography. A left lower lobectomy was performed and both tumors were diagnosed as an adenocarcinoma. Because the histological findings for the atypical epithelial areas of the previous tumor were similar to the two new lesions in this patient, we regarded these tumors as a marginal recurrence.

A Case of Extensive Cellulitis Following a Tube Thoracostomy for a Gas-Forming Empyema

We herein present a case in which extensive cellulitis occurred following a tube thoracostomy for a gas-forming empyema. A 72- year old man was admitted with a fever and cough. A chest computed tomography revealed a large effusion with an air space in the left pleural cavity. A tube thoracostomy was then performed and purulent fluid was recognized. Administration of flomoxef was started after a tube insertion. On the third hospital day, an area of erythema and tenderness was observed around the chest tube insertion site, and on the following day, this area was seen to spread extensively to the left lateral abdomen and the left leg. Subsequent computed tomography revealed widespread subcutaneous swelling with small amounts of air. Laboratory data suggested that multiple organ failure was in progress due to a severe and extensive cellulitis, and the antibiotic was changed to doripenem. Ten days after, the cellulitis had resolved and the laboratory data showed normal result. He has been followed up in our outpatient clinic with no relapse after six months. Although rare, possible occurrences of cellulitis should be considered as a potential complication resulting from a tube thoracostomy for empyema.

Higher Tissue Levels of Thymidylate Synthase Determined by ELISA Are Associated with Poor Prognosis of Patients with Lung Cancer

Thymidylate synthase (TS) is essential in thymidylate biosynthesis and DNA replication. Dihydropyrimidine dehydrogenase (DPD) is a rate-limiting enzyme in pyrimidine catabolism and is important in catabolism of 5-fluorouracil (5-FU). The significance of TS and DPD expressed in lung cancer remains controversial. Here we analyzed the relationship between TS and DPD expression and clinicopathological features of lung cancer. Enzyme-linked immunosorbent assays (ELISAs) were used to measure TS and DPD levels in paired tumor and non-tumor lung tissues obtained from 168 patients (107 adenocarcinomas, 39 squamous cell carcinomas, and 22 others), who had operations at the Shinshu University Hospital from 2004 to 2007 and were followed up for a median of 57.0 months. TS and DPD expression levels were higher in tumor tissues, and TS expression levels were significantly lower in adenocarcinomas than those in other subtypes. In addition, patients with low TS levels survived longer compared with patents with high TS levels. By contrast, DPD expression levels were not correlated with overall patient survival. Importantly, patients with low TS and DPD levels exhibited significantly prolonged survival than those with high TS and DPD. Among the 168 patients, 59 patients were treated with tegafur-uracil (UFT), a DPD-inhibitory fluoropyrimidine, and the UFT-treated patients with high TS and high DPD levels showed worst prognosis. Our study demonstrates a significant correlation between low TS expression levels and long-term prognosis of patients with lung cancer. Thus, ELISA is a clinically useful method to measure TS and DPD expression in lung cancer tissues.

Multiple Schwannomas: Diagnosis and Treatment

Multiple schwannomas occur in association with neurofibromatosis type 2 (NF2) and schwannomatosis. NF2 is a dominantly inherited tumor prediction syndrome which is characterized by bilateral vestibular schwannomas. Schwannomatosis is the third major form of neurofibromatosis and involves the development of multiple schwannomas in the absence of vestibular schwannomas. In general, schwannomas associated with NF2 or schwannomatosis grow slowly and do not become malignant, whereas neurofibromas with NF1 have a propensity for malignant transformation. Usually, these tumors can be detected by magnetic resonance imaging and a diagnosis is made using each criterion. The mainstay of the current treatment for multiple schwannomas is the surgical removal of symptomatic tumors. Considering the natural course of schwannomas and the risk of surgery, the mere presence of a tumor is not an indication for its surgical removal. Radiation therapy is a management option in some patients.